Archives of Cardiovascular Diseases Supplements, 2012
The aim of this study was to analyse the diagnostic accuracy and the clinical usefulness of combi... more The aim of this study was to analyse the diagnostic accuracy and the clinical usefulness of combination of troponin and copeptin for rapid rule out of non ST elevation myocardial infarction (NSTEMI) diagnosis in Emergency Department (ED). Method: This study was an ancillary analysis of a prospective 11 months observational study. Consecutive patients admitted to an university ED for chest pain within 12 hours of ED presentation and without ST elevation on a 12-lead ECG were eligible. Blood samples for determination of copeptin were frozen at-80°C until assayed in a blinded fashion. Patients were classified by two independent physicians (kappa=0.72) as having acute coronary syndrome (ACS) and NSTEMI if cTnI was above 0.1 μg/L on serial testing. Performance of combination of cTnI and copeptin for NSTEMI diagnosis at presentation was studied and clinical utility was assessed by multivariate analysis, area under the curve (AUC) calculation for accuracy, and reporting operating characteristics with 95% confidence intervals. Results: Out of the 641 eligible patients who were recruited, non-ST elevation ACS was diagnosed in 180 patients (28%) including 95 NSTEMI. The negative predictive value of the combination of copeptin and cTnI measures was 97.6% (95% CI 96.4-98.7) versus 92.8% (95%CI 90.8-94.8) with cTnI alone. The patient classification was significantly improved when copeptin was added to the usual diagnostic tools used for NSTEMI management: the AUC of the model with cTnI alone and with cTnI and copeptin were 0.92 (95%CI 0.89-0.95) and 0.94 (95%CI 0.9-0.96) respectively, p<0.05. Conclusion: Combination of copeptin and troponin allows a rapid rule out of NSTEMI at admission in ED and improves the early triage of patients with chest pain.
ObservationNous rapportons l’observation d’un homme de 31 ans, tabagique actif (15 paquets-annee)... more ObservationNous rapportons l’observation d’un homme de 31 ans, tabagique actif (15 paquets-annee), presentant une mutation heterozygote du facteur V (facteur V Leiden) diagnostiquee fortuitement dans le cadre d’un depistage familial, et pris en charge pour un infarctus du myocarde (IDM) avec sus-decalage du segment ST (STEMI) dans le territoire inferieur. La coronarographie, realisee precocement, retrouve une occlusion atherothrombotique TIMI 0 de la coronaire droite (CD) au niveau [...]
Fibrinolysis had long been the reference treatment in patients with ST-Elevation Myocardial Infar... more Fibrinolysis had long been the reference treatment in patients with ST-Elevation Myocardial Infarction (STEMI). It was associated with a large reduction in mortality as compared with delayed or no reperfusion in patients managed early, within the first 2 hours from the onset of symptoms. Fibrinolysis also had well-known potential complications: cerebral haemorrhage, especially in patients beyond 75 years, and reinfarction. Primary percutaneous intervention (PCI) has overcome most of these limitations, but at a price: PCI-related delays that can reduce the expected benefit of primary PCI compared with fibrinolysis. That primary PCI is today the treatment of choice in patients with STEMI is no longer discussed. However, fibrinolysis should still maintain a role in the management of acute myocardial infarction (AMI) for three reasons. First, fibrinolysis is no longer a stand-alone treatment. Modern fibrinolytic strategies combine immediate fibrinolysis, loading dose of thienopyridines, and transfer to a PCI hospital for rescue or early PCI within 24 hours. These strategies capitalize on the hub-and-spoke networks that have, or should have, been built everywhere to implement primary PCI. The overall clinical results of these modern fibrinolytic strategies are now similar to those of primary PCI. Second, a substantial number of patients cannot be managed with primary PCI within the reasonable time thresholds set by the guidelines. In the case of long PCI-related delays, patients will benefit from fibrinolysis before or during transfer to a PCI hospital. Third, modern fibrinolytic strategies-immediate fibrinolysis followed by rescue or early PCI-may even offer the best results of all in a subset of patients. Patients of less than 75 years, managed within the first 2 hours and who cannot have immediate PCI, will fare better with a modern fibrinolytic strategy than with primary PCI. Guidelines advocate regional networks between hospitals with and without PCI capabilities, an efficient ambulance service and standardization of AMI management through shared protocols. These regional logistics of care are essential to take full advantage of fibrinolysis strategies. In order to check that these strategies are correctly applied, networks need ongoing registries, as well as benchmarking and quality improvement initiatives.
European Heart Journal - Cardiovascular Imaging, 2012
Purpose: Ultra-fast cardiac imaging (frame rate (FR) ~500Hz for a 908 sector) can be achieved by ... more Purpose: Ultra-fast cardiac imaging (frame rate (FR) ~500Hz for a 908 sector) can be achieved by transmitting a plane wave (PW) instead of a focused beam. This increased temporal resolution is at the expense of spatial resolution, reducing 2D image quality. However, for functional imaging, temporal resolution gain might outbalance reduced spatial resolution. We aimed to, at an initial stage of development, test the feasibility of PW imaging for myocardial motion estimation in normals. Methods: The septum was imaged in 10 healthy volunteers from the apex by PW and Colour Doppler Myocardial Imaging (CDMI), both with 2.5 MHz transducers. A PW transmit combined with 4 parallel receive beams was implemented on an Epsilon Ultra DCI5000, using B-mode imaging at FR of 212Hz. CDMI data were obtained with a GE Vivid E9. A similar FR was achieved by adjusting the opening angle. Midseptal velocity profiles were extracted from both datasets. The Sum of Absolute Differences was used to obtain the velocity trace from the RF data from the PW system and a commercial software package (GE EchoPac) was used to extract it from the CDMI data. The peak systolic (S') and early (E')/late (A') diastolic velocities were extracted from the PW and CDMI traces. Results: Peak velocity values were comparable between the two modalities: CDMI S' 5.4 + 0.8, PW S' 5.7 + 1.9, CDMI E' 28.5 + 2.3, PW E' 27.6 + 2.2, CDMI A' 25.11 + 1.5 PW A' 24.4 + 1.6, all cm/s, P.0.05. Figure shows positive correlations between PW and CDMI values. Conclusions: Our results demonstrate the feasibility of PW in functional cardiac imaging. The available hardware allowed for a 4x increase in acquisition rate which could be increased with multiple beamformers. PW imaging provides improved temporal resolution in myocardial velocity/deformation imaging.
The recent European Society of Cardiology (ESC) guidelines delineate the diagnosis and management... more The recent European Society of Cardiology (ESC) guidelines delineate the diagnosis and management of distinct categories of acute heart failure syndromes. However, physicians dealing with these patients may need guidance in choosing therapeutic alternatives as soon as the dyspneic patient arrives at the emergency department, until distinct categories of the ESC guidelines are identified. Hence, this manuscript summarizes practical recommendations for the very early management of patients with acute heart failure syndromes. The recommendations are based on a clinical classification system considering the initial systolic blood pressure and other symptoms. Early initiation of diagnostic and goal-directed treatment strategies are key factors in improving patient outcomes. Early and frequent reassessment is also imperative so that adjustments to the initial therapeutic approach can be made, as clinically indicated.
To the Editor, Essential thrombocythaemia (ET) is an acquired myeloproliferative disorder charact... more To the Editor, Essential thrombocythaemia (ET) is an acquired myeloproliferative disorder characterized by excessive proliferation of megakaryocytes and a sustained elevation of platelet count [1]. The life expectancy of ET patients is generally long and similar to an age-matched normal population [2]. One of the complications of ET is a thromboembolic event. The estimated risk for thrombotic episodes is 6.6% per patient-year. In patients over 60 years old this incidence increases to 15.1%. Cytoreductive therapy is given to avoid thrombo-hemorrhagic complications. Hydroxyurea is generally first-line therapy but it may increase the risk of transformation to acute myeloid leukaemia [3]. Considering this risk, anagrelide is a possible choice in younger patients treatment. Several studies have shown that anagrelide is effective in over 80% of cases [1]. However, it can also directly induce serious cardiovascular side effects including, vasospasm of the coronary arteries, congestive heart failure, arrhythmias, and acute coronary syndrome. These side effects are reported in 1-5% of patients treated with anagrelide [1,3-7]. Here, we describe the case of a 44-year-old woman with ET who developed an acute, non-ST-segment elevation myocardial infarction (MI) following the use of anagrelide. This patient had low cardiovascular risk factor, suggesting that anagrelide may have been the cause of her acute MI. A-44-year-old female patient turned up at the emergency department, at the end of July 2012, with retrosternal chest pain reaching the neck, the back and the left arm. The patient had been diagnosed
ABSTRACT Purpose: Atherosclerotic plaques progress in a highly individual manner. Plaque eccentri... more ABSTRACT Purpose: Atherosclerotic plaques progress in a highly individual manner. Plaque eccentricity has been associated with a rupture-prone phenotype and adverse coronary events in humans. Endothelial shear stress (ESS) critically determines plaque growth and low ESS leads to high-risk lesions. However, the factors responsible for rapid disease progression with increasing plaque eccentricity have not been studied. We investigated in vivo the effect of local hemodynamic and plaque characteristics on progressive luminal narrowing with increasing plaque eccentricity in humans. Methods: Three-dimensional coronary artery reconstruction using angiographic and intravascular ultrasound data was performed in 374 patients at baseline (BL) and 6-10 months later (FU) to assess plaque natural history as part of the PREDICTION Trial. A total of 874 coronary arteries were divided into consecutive 3-mm segments. We identified 408 BL discrete luminal narrowings with a throat in the middle surrounded by gradual narrowing proximal and distal to the throat. Local BL ESS was assessed by computational fluid dynamics. The eccentricity index (EI) at BL and FU was computed as the ratio of max to min plaque thickness at the throat. Mixed-effects logistic regression was used to investigate the effect of BL variables on the combined endpoint of substantial worsening of luminal narrowing (decrease in lumen area &amp;amp;amp;gt;1.8 mm2 or &amp;amp;amp;gt;20%) with an increase in plaque EI. Results: Lumen worsening with an increase in plaque EI was evident in 73 luminal narrowings (18%). Independent predictors of worsening lumen narrowing with plaque EI increase were low BL ESS (&amp;amp;amp;lt;1 Pa) distal to the throat (odds ratio [OR] =2.2 [95% CI: 1.3-3.7]; p=0.003) and large BL plaque burden (&amp;amp;amp;gt;51%) at the throat (OR=1.7 [95% CI: 1.0-2.8]; p=0.051). The incidence of worsening lumen narrowing with increasing plaque eccentricity was 30% in the presence of both predictors versus 15% in luminal narrowings without this combination of characteristics (OR=2.4 [95% CI: 1.4-4.3]; p=0.002). Conclusions: Low local ESS independently predicts areas with rapidly progressive luminal narrowing and increasing plaque eccentricity. Coronary regions manifesting an abrupt anatomic change, i.e., at highest risk to cause an adverse event, can be identified early by assessment of ESS and plaque burden.
Background and purpose: Recent genome-wide association studies (GWAS) have identified several gen... more Background and purpose: Recent genome-wide association studies (GWAS) have identified several genetic variants associated with blood pressure (BP). We investigated whether genetic risk scores (GRS) constructed of these variants would be significant predictors for incident cardiovascular (CVD) events in the prospective, population-based setting. Methods: We genotyped 33 genome-wide significant variants in several Finnish cohorts (
Expérience préliminaire avec la pompe Impella Recover ® LP5.0 chez neuf patients en choc cardiogé... more Expérience préliminaire avec la pompe Impella Recover ® LP5.0 chez neuf patients en choc cardiogénique. Une nouvelle assistance ventriculaire gauche en unité de soins intensifs cardiologiques
Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces in... more Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces infarct size when applied immediately after culprit coronary artery re-opening in ST-elevation myocardial infarction (STEMI) patients with thrombolysis in myocardial infarction 0-1 (TIMI 0-1) flow grade at admission. Whether PostC might also be protective in patients with a TIMI 2-3 flow grade on admission (corresponding to a delayed application of the post-conditioning algorithm) remains undetermined. In this multi-centre, randomized, single-blinded, controlled study, STEMI patients with a 2-3 TIMI coronary flow grade at admission underwent direct stenting of the culprit lesion, followed (PostC group) or not (control group) by four cycles of (1 min inflation/1 min deflation) of the angioplasty balloon to trigger post-conditioning. Infarct size was assessed both by cardiac magnetic resonance at Day 5 (primary endpoint) and cardiac enzymes release (secondary endpoint). Ninety-nine patients were prospectively enrolled. Baseline characteristics were comparable between control and PostC groups. Despite comparable size of area at risk (AAR) (38 ± 12 vs. 38 ± 13% of the LV circumference, respectively, P = 0.89) and similar time from onset to intervention (249 ± 148 vs. 263 ± 209 min, respectively, P = 0.93) in the two groups, PostC did not significantly reduce cardiac magnetic resonance infarct size (23 ± 17 and 21 ± 18 g in the treated vs. control group, respectively, P = 0.64). Similar results were found when using creatine kinase and troponin I release, even after adjustment for the size of the AAR. This study shows that infarct size reduction by mechanical ischaemic PostC is lost when applied to patients with a TIMI 2-3 flow grade at admission. This indicates that the timing of the protective intervention with respect to the onset of reperfusion is a key factor for preventing lethal reperfusion injury in STEMI patients. NCT01483755.
Archives of Cardiovascular Diseases Supplements, 2012
The aim of this study was to analyse the diagnostic accuracy and the clinical usefulness of combi... more The aim of this study was to analyse the diagnostic accuracy and the clinical usefulness of combination of troponin and copeptin for rapid rule out of non ST elevation myocardial infarction (NSTEMI) diagnosis in Emergency Department (ED). Method: This study was an ancillary analysis of a prospective 11 months observational study. Consecutive patients admitted to an university ED for chest pain within 12 hours of ED presentation and without ST elevation on a 12-lead ECG were eligible. Blood samples for determination of copeptin were frozen at-80°C until assayed in a blinded fashion. Patients were classified by two independent physicians (kappa=0.72) as having acute coronary syndrome (ACS) and NSTEMI if cTnI was above 0.1 μg/L on serial testing. Performance of combination of cTnI and copeptin for NSTEMI diagnosis at presentation was studied and clinical utility was assessed by multivariate analysis, area under the curve (AUC) calculation for accuracy, and reporting operating characteristics with 95% confidence intervals. Results: Out of the 641 eligible patients who were recruited, non-ST elevation ACS was diagnosed in 180 patients (28%) including 95 NSTEMI. The negative predictive value of the combination of copeptin and cTnI measures was 97.6% (95% CI 96.4-98.7) versus 92.8% (95%CI 90.8-94.8) with cTnI alone. The patient classification was significantly improved when copeptin was added to the usual diagnostic tools used for NSTEMI management: the AUC of the model with cTnI alone and with cTnI and copeptin were 0.92 (95%CI 0.89-0.95) and 0.94 (95%CI 0.9-0.96) respectively, p<0.05. Conclusion: Combination of copeptin and troponin allows a rapid rule out of NSTEMI at admission in ED and improves the early triage of patients with chest pain.
ObservationNous rapportons l’observation d’un homme de 31 ans, tabagique actif (15 paquets-annee)... more ObservationNous rapportons l’observation d’un homme de 31 ans, tabagique actif (15 paquets-annee), presentant une mutation heterozygote du facteur V (facteur V Leiden) diagnostiquee fortuitement dans le cadre d’un depistage familial, et pris en charge pour un infarctus du myocarde (IDM) avec sus-decalage du segment ST (STEMI) dans le territoire inferieur. La coronarographie, realisee precocement, retrouve une occlusion atherothrombotique TIMI 0 de la coronaire droite (CD) au niveau [...]
Fibrinolysis had long been the reference treatment in patients with ST-Elevation Myocardial Infar... more Fibrinolysis had long been the reference treatment in patients with ST-Elevation Myocardial Infarction (STEMI). It was associated with a large reduction in mortality as compared with delayed or no reperfusion in patients managed early, within the first 2 hours from the onset of symptoms. Fibrinolysis also had well-known potential complications: cerebral haemorrhage, especially in patients beyond 75 years, and reinfarction. Primary percutaneous intervention (PCI) has overcome most of these limitations, but at a price: PCI-related delays that can reduce the expected benefit of primary PCI compared with fibrinolysis. That primary PCI is today the treatment of choice in patients with STEMI is no longer discussed. However, fibrinolysis should still maintain a role in the management of acute myocardial infarction (AMI) for three reasons. First, fibrinolysis is no longer a stand-alone treatment. Modern fibrinolytic strategies combine immediate fibrinolysis, loading dose of thienopyridines, and transfer to a PCI hospital for rescue or early PCI within 24 hours. These strategies capitalize on the hub-and-spoke networks that have, or should have, been built everywhere to implement primary PCI. The overall clinical results of these modern fibrinolytic strategies are now similar to those of primary PCI. Second, a substantial number of patients cannot be managed with primary PCI within the reasonable time thresholds set by the guidelines. In the case of long PCI-related delays, patients will benefit from fibrinolysis before or during transfer to a PCI hospital. Third, modern fibrinolytic strategies-immediate fibrinolysis followed by rescue or early PCI-may even offer the best results of all in a subset of patients. Patients of less than 75 years, managed within the first 2 hours and who cannot have immediate PCI, will fare better with a modern fibrinolytic strategy than with primary PCI. Guidelines advocate regional networks between hospitals with and without PCI capabilities, an efficient ambulance service and standardization of AMI management through shared protocols. These regional logistics of care are essential to take full advantage of fibrinolysis strategies. In order to check that these strategies are correctly applied, networks need ongoing registries, as well as benchmarking and quality improvement initiatives.
European Heart Journal - Cardiovascular Imaging, 2012
Purpose: Ultra-fast cardiac imaging (frame rate (FR) ~500Hz for a 908 sector) can be achieved by ... more Purpose: Ultra-fast cardiac imaging (frame rate (FR) ~500Hz for a 908 sector) can be achieved by transmitting a plane wave (PW) instead of a focused beam. This increased temporal resolution is at the expense of spatial resolution, reducing 2D image quality. However, for functional imaging, temporal resolution gain might outbalance reduced spatial resolution. We aimed to, at an initial stage of development, test the feasibility of PW imaging for myocardial motion estimation in normals. Methods: The septum was imaged in 10 healthy volunteers from the apex by PW and Colour Doppler Myocardial Imaging (CDMI), both with 2.5 MHz transducers. A PW transmit combined with 4 parallel receive beams was implemented on an Epsilon Ultra DCI5000, using B-mode imaging at FR of 212Hz. CDMI data were obtained with a GE Vivid E9. A similar FR was achieved by adjusting the opening angle. Midseptal velocity profiles were extracted from both datasets. The Sum of Absolute Differences was used to obtain the velocity trace from the RF data from the PW system and a commercial software package (GE EchoPac) was used to extract it from the CDMI data. The peak systolic (S') and early (E')/late (A') diastolic velocities were extracted from the PW and CDMI traces. Results: Peak velocity values were comparable between the two modalities: CDMI S' 5.4 + 0.8, PW S' 5.7 + 1.9, CDMI E' 28.5 + 2.3, PW E' 27.6 + 2.2, CDMI A' 25.11 + 1.5 PW A' 24.4 + 1.6, all cm/s, P.0.05. Figure shows positive correlations between PW and CDMI values. Conclusions: Our results demonstrate the feasibility of PW in functional cardiac imaging. The available hardware allowed for a 4x increase in acquisition rate which could be increased with multiple beamformers. PW imaging provides improved temporal resolution in myocardial velocity/deformation imaging.
The recent European Society of Cardiology (ESC) guidelines delineate the diagnosis and management... more The recent European Society of Cardiology (ESC) guidelines delineate the diagnosis and management of distinct categories of acute heart failure syndromes. However, physicians dealing with these patients may need guidance in choosing therapeutic alternatives as soon as the dyspneic patient arrives at the emergency department, until distinct categories of the ESC guidelines are identified. Hence, this manuscript summarizes practical recommendations for the very early management of patients with acute heart failure syndromes. The recommendations are based on a clinical classification system considering the initial systolic blood pressure and other symptoms. Early initiation of diagnostic and goal-directed treatment strategies are key factors in improving patient outcomes. Early and frequent reassessment is also imperative so that adjustments to the initial therapeutic approach can be made, as clinically indicated.
To the Editor, Essential thrombocythaemia (ET) is an acquired myeloproliferative disorder charact... more To the Editor, Essential thrombocythaemia (ET) is an acquired myeloproliferative disorder characterized by excessive proliferation of megakaryocytes and a sustained elevation of platelet count [1]. The life expectancy of ET patients is generally long and similar to an age-matched normal population [2]. One of the complications of ET is a thromboembolic event. The estimated risk for thrombotic episodes is 6.6% per patient-year. In patients over 60 years old this incidence increases to 15.1%. Cytoreductive therapy is given to avoid thrombo-hemorrhagic complications. Hydroxyurea is generally first-line therapy but it may increase the risk of transformation to acute myeloid leukaemia [3]. Considering this risk, anagrelide is a possible choice in younger patients treatment. Several studies have shown that anagrelide is effective in over 80% of cases [1]. However, it can also directly induce serious cardiovascular side effects including, vasospasm of the coronary arteries, congestive heart failure, arrhythmias, and acute coronary syndrome. These side effects are reported in 1-5% of patients treated with anagrelide [1,3-7]. Here, we describe the case of a 44-year-old woman with ET who developed an acute, non-ST-segment elevation myocardial infarction (MI) following the use of anagrelide. This patient had low cardiovascular risk factor, suggesting that anagrelide may have been the cause of her acute MI. A-44-year-old female patient turned up at the emergency department, at the end of July 2012, with retrosternal chest pain reaching the neck, the back and the left arm. The patient had been diagnosed
ABSTRACT Purpose: Atherosclerotic plaques progress in a highly individual manner. Plaque eccentri... more ABSTRACT Purpose: Atherosclerotic plaques progress in a highly individual manner. Plaque eccentricity has been associated with a rupture-prone phenotype and adverse coronary events in humans. Endothelial shear stress (ESS) critically determines plaque growth and low ESS leads to high-risk lesions. However, the factors responsible for rapid disease progression with increasing plaque eccentricity have not been studied. We investigated in vivo the effect of local hemodynamic and plaque characteristics on progressive luminal narrowing with increasing plaque eccentricity in humans. Methods: Three-dimensional coronary artery reconstruction using angiographic and intravascular ultrasound data was performed in 374 patients at baseline (BL) and 6-10 months later (FU) to assess plaque natural history as part of the PREDICTION Trial. A total of 874 coronary arteries were divided into consecutive 3-mm segments. We identified 408 BL discrete luminal narrowings with a throat in the middle surrounded by gradual narrowing proximal and distal to the throat. Local BL ESS was assessed by computational fluid dynamics. The eccentricity index (EI) at BL and FU was computed as the ratio of max to min plaque thickness at the throat. Mixed-effects logistic regression was used to investigate the effect of BL variables on the combined endpoint of substantial worsening of luminal narrowing (decrease in lumen area &amp;amp;amp;gt;1.8 mm2 or &amp;amp;amp;gt;20%) with an increase in plaque EI. Results: Lumen worsening with an increase in plaque EI was evident in 73 luminal narrowings (18%). Independent predictors of worsening lumen narrowing with plaque EI increase were low BL ESS (&amp;amp;amp;lt;1 Pa) distal to the throat (odds ratio [OR] =2.2 [95% CI: 1.3-3.7]; p=0.003) and large BL plaque burden (&amp;amp;amp;gt;51%) at the throat (OR=1.7 [95% CI: 1.0-2.8]; p=0.051). The incidence of worsening lumen narrowing with increasing plaque eccentricity was 30% in the presence of both predictors versus 15% in luminal narrowings without this combination of characteristics (OR=2.4 [95% CI: 1.4-4.3]; p=0.002). Conclusions: Low local ESS independently predicts areas with rapidly progressive luminal narrowing and increasing plaque eccentricity. Coronary regions manifesting an abrupt anatomic change, i.e., at highest risk to cause an adverse event, can be identified early by assessment of ESS and plaque burden.
Background and purpose: Recent genome-wide association studies (GWAS) have identified several gen... more Background and purpose: Recent genome-wide association studies (GWAS) have identified several genetic variants associated with blood pressure (BP). We investigated whether genetic risk scores (GRS) constructed of these variants would be significant predictors for incident cardiovascular (CVD) events in the prospective, population-based setting. Methods: We genotyped 33 genome-wide significant variants in several Finnish cohorts (
Expérience préliminaire avec la pompe Impella Recover ® LP5.0 chez neuf patients en choc cardiogé... more Expérience préliminaire avec la pompe Impella Recover ® LP5.0 chez neuf patients en choc cardiogénique. Une nouvelle assistance ventriculaire gauche en unité de soins intensifs cardiologiques
Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces in... more Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces infarct size when applied immediately after culprit coronary artery re-opening in ST-elevation myocardial infarction (STEMI) patients with thrombolysis in myocardial infarction 0-1 (TIMI 0-1) flow grade at admission. Whether PostC might also be protective in patients with a TIMI 2-3 flow grade on admission (corresponding to a delayed application of the post-conditioning algorithm) remains undetermined. In this multi-centre, randomized, single-blinded, controlled study, STEMI patients with a 2-3 TIMI coronary flow grade at admission underwent direct stenting of the culprit lesion, followed (PostC group) or not (control group) by four cycles of (1 min inflation/1 min deflation) of the angioplasty balloon to trigger post-conditioning. Infarct size was assessed both by cardiac magnetic resonance at Day 5 (primary endpoint) and cardiac enzymes release (secondary endpoint). Ninety-nine patients were prospectively enrolled. Baseline characteristics were comparable between control and PostC groups. Despite comparable size of area at risk (AAR) (38 ± 12 vs. 38 ± 13% of the LV circumference, respectively, P = 0.89) and similar time from onset to intervention (249 ± 148 vs. 263 ± 209 min, respectively, P = 0.93) in the two groups, PostC did not significantly reduce cardiac magnetic resonance infarct size (23 ± 17 and 21 ± 18 g in the treated vs. control group, respectively, P = 0.64). Similar results were found when using creatine kinase and troponin I release, even after adjustment for the size of the AAR. This study shows that infarct size reduction by mechanical ischaemic PostC is lost when applied to patients with a TIMI 2-3 flow grade at admission. This indicates that the timing of the protective intervention with respect to the onset of reperfusion is a key factor for preventing lethal reperfusion injury in STEMI patients. NCT01483755.
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